Rapid Clinical Updates: Inpatient Management of Cirrhosis-Handout

Handout

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This document from hospitalmedicine.org summarizes current and emerging approaches in the inpatient management of cirrhosis, focusing on key complications including ascites, hepatic encephalopathy (HE), hepatorenal syndrome-acute kidney injury (HRS-AKI), and gastrointestinal (GI) bleeding.<br /><br />Ascites, characterized by fluid accumulation in the peritoneal cavity due to altered hydrostatic and oncotic pressures, mobilizes at a maximal rate of 1L/day. Paracentesis is the recommended procedure for diagnosing spontaneous bacterial peritonitis (SBP) during acute decompensation and is safe despite coagulopathy. While diuretics help reduce ascites, strict fluid restriction can increase thirst and ADH secretion, potentially worsening cirrhosis-related pathology.<br /><br />Hepatic encephalopathy results from systemic accumulation of toxins normally cleared by the liver. Early and aggressive treatment with lactulose remains the cornerstone therapy, with rifaximin as an adjunct to reduce recurrence. Diagnosis relies on clinical symptoms ranging from subtle sleep-wake disturbances to coma, while ammonia levels are not clinically useful.<br /><br />Hepatorenal syndrome-AKI carries a poor prognosis and limited therapeutic advancement. Diagnosis requires an albumin challenge; vasopressors such as terlipressin or norepinephrine may be initiated for refractory cases. Positive prognostic indicators include elevated mean arterial pressure and increased urine output.<br /><br />GI bleeding, driven by portal hypertension causing varices and worsened by coagulopathy, is managed acutely with octreotide to lower portal pressure and ceftriaxone to prevent infection, alongside prompt endoscopic banding. Red blood cell transfusions are recommended only when hemoglobin falls below 7 g/dL; fresh frozen plasma transfusions do not improve coagulation and may exacerbate portal pressures.<br /><br />Overall, this synthesis integrates current standards of care with emerging evidence to optimize management of cirrhosis complications in hospitalized patients.

Keywords

cirrhosis

ascites

hepatic encephalopathy

hepatorenal syndrome-AKI

gastrointestinal bleeding

paracentesis

lactulose

rifaximin

terlipressin

endoscopic banding